Charting a Path Through a Troubled Legacy

JOEL BERVELL: Hey, everyone. Welcome back to another season of The Dose. I’m your host, Joel Bervell. On this season, we’re diving deeper on the work being done to close the gap on health disparities in the United States. From chronic disease management to clinical trials and even the expanding role of private equity in health care, we’re exploring the forces shaping who gets care, how it’s delivered, and at what cost.

And throughout it all, one key theme will keep rising to the top — data.

At a time where federal efforts are being made to defund key health research institutions, the very metrics we rely on to measure progress are under threat. But when we measure what counts, we move closer to what matters most: better, more equitable health outcomes for everyone.

I truly can’t wait for you to hear this season’s conversations. Let’s get into it.

My guest on this episode of The Dose is Dr. Aletha Maybank, a physician, executive, and public health advocate. She’s worked at the CDC and the New York City Department of Public Health. Most recently, Dr. Maybank served as the American Medical Association’s inaugural chief health equity officer for five and a half years.

There, she developed initiatives and conversations that were in many ways challenging — not only to the status quo in health care delivery but to the organization itself. Dr. Maybank’s work at the AMA was groundbreaking, necessary, and often not easy, as acknowledged by the president of the organization. Today, she’s here to share her insights and I’m so happy to have our listeners on The Dose hear from her.

Thank you so much for joining me, Dr. Maybank.

ALETHA MAYBANK: Oh, thanks for having me. So happy to be here.

JOEL BERVELL: For those listeners that don’t know much about the American Medical Association, aka the AMA, I think it’s important to start with some historical context that frames the importance of the work that you are doing.

So, from the AMA’s very inception, exclusion and resistance to inclusion had been embedded in its history. Dr. Nathan Smith Davis, who was the AMA founder, played a large role in shaping the culture. I’m curious if you could talk about who he was or even how his attitudes influenced the AMA over the past 175 years.

ALETHA MAYBANK: Well, thanks for that question. And I think there’s several things that I like to say and that I’ve kind of come to from working at several institutions over the years and institutions that I’m going to frame as historically white, because oftentimes I know AMA gets elevated as kind of the poster child of, I’ll say in this way, racial injustice.

But to be really clear that many institutions of that time also projected harms, whether it’s through culture or policy that have been well documented on the communities that were being served or the communities across this country, not only being served but the professions that were in them as well. That, if you didn’t identify potentially as white and male, that there was some level of context that said, whether it was in policy again or culture, that you weren’t welcome and that you were excluded from opportunities.

And so I like to kind of frame that AMA was not the only one, and that was the institution that I was definitely at and working at and had the opportunity to work with you and many others, and you all really inspired me. We can talk a little bit more about that and how I led the work. But understanding that the self-proclaimed father of the AMA, and this is all again written and documented, very much a part of, I think, the evolution of health care overall within this country because it’s a very influential institution, lots of influence in politics and in government.

I mean, it’s organized medicine. That is the nature of it. When people say health isn’t political, I said, “Well, the whole premise of organized medicine is understanding the importance and leverage of policy as well as politics.” And so this organization, from day one, was kind of early on, very clear in the language that Black physicians and particularly were going to have some level of exclusion. And that was quite, again, explicit. It’s documented. And so it ended up really contributing to the exclusion of Black physicians for over a hundred years.

It really wasn’t until the Civil Rights Movement that you kind of saw then the changing of policy within the association. And that had a lot of impact on the ability of Black physicians to get hospital privileges over the years because, at one point in time, you actually had to have a membership with AMA in order to get hospital privileges, or some local affiliate. So that’s had significant impacts on the health care workforce for physicians along with many other things as it relates to Black physicians.

JOEL BERVELL: Absolutely. And I mean, you’ve traced out that kind of legacy and that history, how it took until the Civil Rights Movement. And yet it wasn’t even until 2008, right, that the American Medical Association formally issued a public apology for its role in perpetuating a lot of racist practices in medicine.

For decades, the exclusion and obstruction of Black physicians didn’t just limit careers. It had profound and lasting impacts on the health of Black Americans too. I think we both intimately understand how that happens, whether we’re looking at things like Black Americans facing higher levels of maternal mortality rates, disproportionate rates of misdiagnosis, or even lower access to culturally competent care. And all of that can be traced in part to historic exclusion by multiple organizations as you laid out.

I’m curious. Despite the apology, there was little meaningful action that happened afterwards for more than a decade. What were the key factors that transformed it from just a statement of saying, “We apologize for what happened,” into real institutional change that ultimately led to your appointment to a position that could actually foster change?

ALETHA MAYBANK: Yes, thanks for the question. I think I’m very careful about answering it because I wasn’t there in the 10 years, but I think depending on who you ask within the institution is going to depend on what the answer is. I will say, though, there were many, and this happens within institutions oftentimes. There’s a lot that’s invisible.

And a lot of times, you will not hear about the people who have been advocating and who did advocate, who did speak up, and work that did happen. It’s almost . . . it’s like any kind of movement in a way, right? It takes time to build that power, and there could be external things happening in the environment or in our country that also lead to a particular moment.

And so there was a commission to end and eliminate disparities that had almost the entirety of organized medicine engaged and involve the National Medical Association. There were lots of places where centers for health equity were already popping up for years. The first Office of Minority Health was 1986 from the U.S. Department of Health under Secretary Margaret Heckler.

After doing some research and collecting data, actually the surveillance data that they collected, seeing the disparities that existed, especially amongst Black Americans, and from there launching the Office of Minority Health at the federal level. And then you saw states and local localities also launching the Office of Minority Health. So you started to see the evolution of the work and the words to be inclusive of equity. And so I started in 2019 to do this.

JOEL BERVELL: Mm-hmm. So you convened some conversations during your time at the AMA about restorative justice. First, can you define what restorative justice is for listeners who may not be familiar, and can you talk about how those conversations got launched in the first place?

ALETHA MAYBANK: I’m really glad you asked about restorative justice because I really feel that we were really on the front edge and front line of equity work. And so it’s really another framework that provides a valuable approach in health care. It prioritizes the personal connection and humanistic values that really attracted most of us, as physicians really, to the field.

So it embraces community power as well as active accountability, making sure people do what they say they’re going to do, and then all the same time is to preserve the safety and dignity of all of us. The process typically in which you engage restorative justice is more collaborative in its framing and includes three things of, one, acceptance and acknowledgment of responsibility for the harmful behavior of the past or present. And two, repairing of that harm to individuals and to the community. And three, rebuilding of trust by showing understanding of the harm, addressing the kind of personal and collective issues, and then building more positive social connections.

JOEL BERVELL: And I know that practice isn’t unique only to the AMA. The Canadian Medical Association and others have also engaged in those types of conversations and initiatives.

ALETHA MAYBANK: Absolutely.

JOEL BERVELL: But they seem like really hard conversations to have.

I know that there’s a lot of work happening when it comes to restorative justice in medical education. Something that I’m really interested in as the past five years I’ve gone through medical school and seen it actually change how we’re receiving curriculum even, right? And so, I’m curious if you can describe some of what’s being incorporated into medical school curriculum right now on this front and if you foresee programs getting traction and having this become a more standardized way of training future doctors.

ALETHA MAYBANK: You know, there’s the hope, but we have to be real of the time that we’re in at this moment, right? We know there are attacks on anything with a mention diversity, equity, and inclusion. And so if we’re able to understand that this is all about how are we achieving optimal health for all, and we believe that everyone deserves health, deserves health with dignity, and that in order to do that, we have to understand what we’ve done in the past in order to not do them again in the future, then I think there’s a path forward.

And you don’t even have to use the words that tend to be trigger words for people, but that’s if that’s the belief system. I think now we’re definitely in a time where it’s really difficult to just even speak and mention these words in places. People are afraid. I understand the fears. They’re afraid to speak up. Some people are speaking up and we’re going to need more people to speak up for sure.

I worked very closely at times with AAMC and working on how to support curriculum development and ensuring that, at all levels of training, we’re learning about ways where we may be excluding people, potentially harming people, and making sure that we are providing the best care for all people, not just one group, but literally all people. I think more of that needs to be done, and I feel restorative justice practice is part of that.

I mean, they’re really principles, collaborative decision-making. And there’s ethical principles in there too, not doing harm, that are very important to us as physicians and that we’re not going to harm moving forward. So there’s a lot of alignment actually, naturally, with restorative justice and our code of ethics as physicians. You need to have a diverse workforce that contributes to health equity, but that’s not the only thing that contributes to health equity, right?

It’s about changing mindsets and how information is received and how information and solutions are designed, not just who’s designing them, but how are they being designed. And so health equity then, also another tool, but these were tools to help support ensuring accountability for civil rights. And I feel we’ve lost that frame in this whole conversation. I think about maternal health as an example, maternal morbidity and mortality. If folks are dying over and over again consistently at certain hospitals, then what accountability is there?

JOEL BERVELL: Yeah, there’s so much in what you said that I can respond to, but I think what I really loved is the idea that you’re saying that we already, this code of ethics that we get as physicians is already so in line with the idea of restorative justice. And the more that we see those commonalities, the better we’re actually able to work them and live them and actually reach these goals at the end of the day.

And in thinking about that and developing frameworks, you developed an 80-plus page strategic plan for the AMA. Actually, two plans. With the first, that was looking at goals from 2021 to 2023, and the second from 2024 and extending into 2025. And I wanted to dive into some of that, but first wanted to hear about the narrative guide that you also developed and published. Curious about what motivated that and how it was received when you were working on it.

ALETHA MAYBANK: For me, narrative has always been a thread of my career. Understanding, first, that narrative is power and whomever’s controlling the narrative has power. And oftentimes, some of those narratives that are in power are dominant, and sometimes they’re malignant. They’re not helpful. They’re harmful in how we frame what people are, who they are, and how they’re operating.

And that we needed to expose that and shed some light on those narratives so that, as health professionals, we could see for ourselves how oftentimes we’re actually harboring those narratives ourselves because we are in positions of power, we’re in institutions of power, we’re in a field of power. And so how we may be holding those and contributing potentially to inequities unintentionally. So, I felt we couldn’t just collect more data. People needed to understand their own personal mindsets, their language, and the narratives, and how culture influences them, and vice versa, how they can influence culture as well as policy.

And so that was a really critical piece, and I’ve learned that actually when I was more so at the New York City Department of Health working for one . . . a pioneer in narrative and health is Richard Hofrichter, who was at the National Association of City and County Health Officials. And he released a whole document on kind of advancing the public narrative as it relates to health, but understanding we had to disrupt that for the medical community. Folks want to have control of the narrative because when you control the narrative, you can control so much. And the reaction to the guide was, for the most part, very positive from certain corporations that weren’t even in the medical field that were taking it on and adopting the language from it, and certain med schools were definitely taking it on and embracing it.

And then there was definite folks that didn’t like it. And it was around that time when it was released that I started to receive . . . to really understand what it meant to have violent action towards me directly. I started to receive some threats. I’ve said this publicly as well, and it’s been written up about, but somebody came to my door, home door, and wrote Die with the B-word on it.

JOEL BERVELL: Wow.

ALETHA MAYBANK: And I had to have security detail for a certain amount of months. AMA provided that and supported all of that and my protection, and that’s not unique to me. We’ve seen an increase on attacks on health care professionals overall within this country. So narrative, you pick at narrative, you’re going to get some reaction.

JOEL BERVELL: Absolutely. Well, first of all, thank you for sharing all of that and for sharing how frightening it can be to be in this space as well, or you have to think about your own protection.

I think, for many listeners, they may not actually think about how important narrative is, but also when you change narrative, how there’s pushback against it, and how you are . . . you’ve literally been putting yourself on the line in order to make health care more equitable for everyone. And so, thank you. I just want to take a moment and say thank you for everything that you’ve done through that stance as well.

ALETHA MAYBANK: Thank you.

JOEL BERVELL: I know, speaking of narrative, language is very important to narrative as well, and the report included a glossary. Curious how and why was the glossary developed. And you talked a little bit about how other individuals, both within health care and outside of health care, have picked it up. So curious about how it’s been used by others.

ALETHA MAYBANK: There’s just a lot of words. That’s the other thing I noticed in my shift from public health to health care especially, because they’re just really two very different spaces, and I didn’t realize that from spending most of my career in public health.

And I said to myself, “My goodness, like how can people talk and really fully communicate if you’re using different language and your narratives behind that language are also very different.” So, finding a common language so that we could have better conversations with one another so that we can advance whatever it needed to be around this context of health, especially as it related to equity. So that was the intention behind it.

JOEL BERVELL: Absolutely. Level setting, get everyone on the same page to . . .

ALETHA MAYBANK: To the best . . .

JOEL BERVELL: . . . what we’re actually working towards.

ALETHA MAYBANK: Yeah, to the best of the ability and understanding, again, language changes. And I think it’s important to recognize, and I think I’ve evolved myself. I used to be very particular about language, but what I realized is that it’s not about policing language. You have to kind of sit and understand, and this is where relationships becomes really important, where proximity to people becomes really important, consistency, transparency, building trust.

When you have those things, it is easier to communicate even when your words are different because there’s some level of grace and understanding of the person’s intention. And so you don’t take offense to what they’re saying. You kind of sit there, and you’re like, “What are they really trying . . . let me try to understand this and be more curious and inquisitive about that to get to that point where we are now in the same point of the conversation and can move forward.”

JOEL BERVELL: I love that. Bringing it back to the strategic plans. More broadly, the strategic plans were really looking at a systems change approach. I’m curious if you can talk about the foundational systems that you were looking to fix with the strategic plan and how was that progress assessed.

ALETHA MAYBANK: Yeah. So I think, fundamentally, understanding that there are multiple systems that are interacting and intersecting together that produce good health and produce bad health, right? It’s not just one pathway and one system such as health care, but we have all these other systems that are in our country.

So whether it’s travel, the environments and systems that allow us to find nourishment, and that’s food and the things that we need to put into our body, the systems that help us eliminate waste, the systems, all of these things are interlocking, and they impact our health overall.

JOEL BERVELL: Mm-hmm. Mm-hmm.

ALETHA MAYBANK: And so that is kind of what we were looking to, again, expose and more disrupt so that it wasn’t this narrow conversation around what health is, and that is all about just the health care system and the doctor’s office or the hospital systems in which we interact with, but it’s all these other things.

Also, finance, right. Finance is a big one in our economy, but not talked about by most Americans, and even health professionals in this country, about the influences of finances and politics. And the context that really wealth-building and the ability to build wealth is one of the greatest predictors of whether you have good health or not.

I think a lot of our work and the work over my career and even now moving forward has that kind of lens to it. How are we exposing and expanding this narrative around what creates health? Even in your homes and how you talk about it and how we educate on health, that really all policy actually ends up being health policy.

JOEL BERVELL: Absolutely. And I do want to ask about commitment to increased training. So right now, about 5 percent of doctors in the United States are Black, and about 9 percent are Hispanic. One of the initiatives included a recognition of the gap between our physician workforce and the population of the United States. The strategic plan called for a commitment to increasing training. How do we actually get to increased representation in medicine?

ALETHA MAYBANK: This is one of those areas where sometimes I would say some things just aren’t rocket science, truthfully. You look at HBCUs and some of the Native American–serving schools — they figure it out. They are able to enroll students of all types of backgrounds and numbers that are more representative of what exists in this country, and graduate them, and support them. To me then, there’s no reason why it couldn’t be done in other places. To me this is about will.

JOEL BERVELL: Absolutely. And there’s pushbacks when you do try to at some points. And that backlash can sometimes be even more ferocious than before.

ALETHA MAYBANK: Yeah, it’s the context. Backlash is also a relative thing too, right. We are . . . that is a condition. It exists in this country. It has always existed. And so we operate like it’s backlash, but we need to operate like it exists, it’s here, and we need to have something that counters what has always been inherent in this country and how it has been founded. And until we kind of have that shift and not react to the backlash, we are always going to be reacting.

JOEL BERVELL: But the work, as you’re mentioning, still continues. There’s so much to do still. As you look ahead, how would you characterize the promise of institutional-level change to affect patient care and outcomes?

ALETHA MAYBANK: When you think about what creates hope in this moment, just thinking about all the folks who were before us, who were also . . . who had even worse conditions than we have now, of which they continued to fight for justice, right? And so . . . and all of them who told us that freedom is not given, it’s not freely given, that we are going to have to continue to fight for it. That got lost but we have to continue to fight for it as a collective within the context of our health institutions.

So, when I think about an institution at this moment in time and its ability and commitment to continue with institutional and internal change, we see they’re struggling, right? We hear it over and over, from whether it’s layoffs or just silenced period, and I have to believe that we have the opportunity still at some point in time to rely on the institutions. They haven’t been designed really for the majority of people within this country to really work for the majority of people in this country.

And so we can’t only rely on the institution in the way it’s designed in order to save us or to change the system of health or health care. I think this is a larger organizing effort that takes external and internal forces to evolve us to where we need to be to have a better health care system. But I think we have to have a better sense of how we understand and treat human beings in general within this country.

JOEL BERVELL: Absolutely. And to end, I’d love to hear about some of the work that you are going to be doing in the future, if you’re able to share any of that.

ALETHA MAYBANK: Yeah. Sure. I mean, I grew up in the arts, and so . . . and I feel the arts is just a very valuable vehicle to be able to pull people in to talk about and engage around health as well as to deliver health through. So I’ve been working with some folks around that.

I started a film studio as well, Truth Light, with some friends and colleagues, again, really geared towards unearthing the narratives that often don’t get exposed and the people’s stories that often don’t get shared in a public way but with a lens of health.

I think a lot of the TV shows and movies that are out around health are very like hospital-centric, very physician-centric, and I’m like, there’s such a broader context of how we could be communicating around health. So I’m very interested in doing that kind of work, and I’ve just been consulting and advising, and I’m supposed to be resting, so I’m doing a little bit of that as well.

JOEL BERVELL: Well, Dr. Maybank, I want to say thank you so much for joining me for this conversation. Thank you so much for all the work you’ve done, and I know will continue to do.

ALETHA MAYBANK: Thank you. Thanks, Joel. Very proud of you.

JOEL BERVELL: This episode of The Dose was produced by Jody Becker, Mickey Capper, and Naomi Leibowitz. Special thanks to Barry Scholl for editing, Jen Wilson and Rose Wong for art and design, and Paul Frame for web support. Our theme music is “Arizona Moon” by Blue Dot Sessions. If you want to check us out online, visit thedose.show. There, you’ll be able to learn more about today’s episode and explore other resources. That’s it for The Dose. I’m Joel Bervell, and thank you for listening.